Wellsville Health Care Center

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a full-time Director of Nursing (DON) 24 hours a day, seven days a week with an average daily occupancy of 60 or more residents. The facility census was 62. 1. Review showed the did not provide a policy for DON coverage. 2. Review of the Facility Assessment, dated 07/07/25, showed staff documented an average daily census of 62.3. Review of the facility nursing staff daily logs and facility daily census showed: -08/08/25: Facility census 66; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/09/25: Facility census 65; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/10/25: Facility census 65; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/14/25: Facility census 64; from 6:00 A.M., to 6:00 P.M., the DON worked as the charge nurse;-08/15/25: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three residents' (Resident #3, #4, and #5) out of nine sampled residents remained free from physical abuse when Resident #2 who had a history of physical aggression physically assaulted the residents. The facility census was 65.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure there was a licensed nurse onsite to provide necessary nursing care and services 24 hours a day, seven days a week. The facility census was 65. 1. Review of the Facility's policies showed staff did not provide a policy for Licensed Nurses. Review of the Facility Assessment, dated 04/18/25, showed staff documented the facility required three Licensed Practical Nurses (LPNs) daily. Review of the Nurse Staff Schedule, dated October 2024, showed staff did not ensure 24-hour a day licensed nurse coverage on: -10/19/24 for 11 hours and 18 minutes; -10/20/24 for 15 hours and 52 minutes; -10/27/24 16 hours; -10/28/24 6 hours. Review of the Nurse Staff Schedule, dated November 2024, showed staff did not ensure 24-hour a day licensed nurse coverage on: -11/02/24 for 17 hours and 26 minutes; -11/03/24 for 9 hours and 30 minutes; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 65. 1. Review of the facility's RN policy, revised on 04/30/24, showed the facility will utilize the services of a RN for at least eight consecutive hours per day, seven days per week. Review of the facility Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2024, Quarter 4 (October 1 through December 31) showed triggers for no RN hours for 10/13, 10/15, 10/19, 10/21, 10/26, 10/27, 11/02, 11/24, and 12/02. Review of the Facility Assessment, dated 04/18/25, showed staff determined one Registered Nurse (RN) should be staffed daily. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination, out-dated use and the reuse of single-service food containers. Facility staff failed to maintain kitchen equipment and floors clean and in good repair. Facility staff failed perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff also failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor waste containers remained covered when not in actual use. These failures have the potential to affect all residents. The facility census was 65. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed maintain a safe, clean, comfortable and homelike environment, when staff failed to ensure resident areas were in good repair, failed to maintain the interior of the building and failed to maintain equipment. The facility census was 65 with a capacity of 112. 1. Review of the policies provided by the facility showed the records did not contain a policy related to upkeep of the facility's physical environment. 2. Observation on 05/05/25 at 11:33 A.M., showed resident occupied room [ROOM NUMBER] with black scuff marks along the wall under the window. Observation on 05/05/25 at 11:42 A.M., showed resident occupied room [ROOM NUMBER] with damaged drywall between the residents beds around the call light outlet; [...]

Inspectors wroteBased on record review and interview, facility staff failed to check the Employee Disqualification List (EDL), Family Care Safety Registry (FCSR), or complete a Criminal Background Check (CBC) for two sampled employees (Certified Nurse Aid (CNA) R, and Nurse Aide (NA) S), out of eight sampled newly hired employees. The facility failed to check the NA Registry for seven employees (Housekeeper T, Dietary Aide U, CNA V, CNA R, Licensed Practical Nurse (LPN) D, NA S and Registered Nurse (RN) E) out of eight sampled employees. The facility census was 65. 1. Review of the facility's policy titled Abuse and Neglect, dated 06/12/24, showed potential employees are screened for a history of abuse, neglect or mistreating of residents. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for seven residents (Resident #4, #5, #14, #25, #28, #56, and #57) out of 24 residents sampled. The facility census was 65. 1. Review of the facility's policy titled Bed Hold, revised 11/06/23, showed when a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide the resident or their legal representative a copy of the bed hold policy. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and update the plan of care with changes in the residents' care needs for ten residents (Residents #3, #4, #5, #6, #7, #10, #18, #25, #34, and #56) out of 20 sampled residents. Facility staff failed to hold care conferences for three residents (Resident #3, #10, and #21). The facility census was 65. 1. Review of the facility policy titled Comprehensive Care Plans, dated 10/31/24, showed the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. [...]

Inspectors wroteBased on interview and record review, facility staff failed to communicate pharmacy recommendations to the physician for four residents (Resident #6, #10, #18, and #34) to prevent or minimize adverse consequences related to medication therapy to the extent possible out of 20 sampled residents. The facility census was 65. 1. Review of facility policy titled Pharmacy Services Policy, dated 05/18/24, showed the facility will employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support resident's healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure nurse aides (NA) received the required 12 hours of training annually. The facility census was 65. 1. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the Facility Assessment, dated 04/18/25, showed staff were to have the following trainings annually: Preventing, Recognizing, and Reporting Abuse; Resident Rights; Health Insurance Portability and Accountability Act (HIPAA); Culture change- person centered care; Infection control; Dementia management; Disaster planning and procedures; and Caring for residents with Alzheimer's, dementia, mental illness, and specialized care. Review of the facility's Census and Condition of Residents, dated 05/06/25, showed staff documented twelve residents resided in the facility with diagnoses of dementia and/or Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to accommodate resident needs and preferences, when staff failed to supply the correct size briefs for one resident (Resident #3) of four sampled, and failed to maintain a sit-to-stand lift (mechanical lift used for residents who can bear their own weight) in good repair for one resident (Resident #5) of four sampled residents. The facility census was 65. 1. Review of the facility's policy titled Resident Rights - Missouri, revised 07/05/23, showed residents have the right to reside and receive services with reasonable accommodation of individual needs and preferences, and the right to participate in his/her care. 2. [...]

Inspectors wroteBased on observation, interview, and record review, licensed staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to remove and discard discontinued medication and improperly labeled medication from one sampled medication cart. The facility census was 65. 1. Review of the facility's policy titled Medication Storage Policy, dated 05/18/25, showed all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. Review of the facility's policy titled Administration of Insulin Policy, dated 05/14/25, showed insulin pens once opened should be disposed of after 28 days or according to manufacturer's recommendation. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of sexual abuse between two residents (Resident #1 and Resident #2) to the Department of Health and Senior Services (DHSS) within the two hour timeframe. The facility census was 57. 1. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed an alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown origin and misappropriation of resident property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury and twenty four hours is the alleged violation does not involve abuse and has not resulted in serious bodily injury. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow their Abuse and Neglect Policy when staff failed to investigate an allegation of resident to resident sexual abuse. The facility census was 57. 1. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed an alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown origin and misappropriation of resident property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury and twenty four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. It directs the Administrator or designee will at a minimum: -Investigate all allegations and types of incidents; -Call 911; [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of funds for one resident's (Resident #1) when the former administrator requested and accepted $800 from the resident's digital wallet service application account into the administrators personal digital wallet service application account. The facility census was 47. The administrator was notified on 10/22/24 of past Non-Compliance which occurred on 4/29/24. On 10/11/24 Resident #1 reported he/she sent the former Administrator $800 to his/her personal digital wallet service application account to pay a bill owed to the facility and the money was not applied to the resident's bill. Upon discovery on 10/11/24 staff reported the allegation of misappropriation, started an investigation, and inserviced staff on misappropriation of resident funds. Staff corrected the deficient practice on 10/18/24. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment for residents, when staff failed to maintain floors, windows, and equipment in resident rooms clean and in good repair. The facility census was 45. 1. The facility did not provide a policy for staff to report environmental concerns. 2. Observation on 9/17/24 at 10:30 A.M, showed the 100 hall floors contained multiple areas of debris. Observation on 09/25/24 at 9:09 A.M., showed the 100 hall floors contained dead bugs, a dried sticky substance, and debris. 3. Observation on 9/17/24 at 10:32 A.M, showed the 200 hall floors contained multiple areas of debris. Observation on 09/25/24 at 9:12 A.M., showed the 200 hall floors contained dead bugs, a dried sticky substance, and debris. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 38. 1. Review of facility provided policies showed staff did not provide a policy related to the qualifications of kitchen staff. Review of the Dietary Manager's (DM) personnel record showed the DM hire date as a part time cook in February 2023. Review showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus. Facility staff failed to ensure meal substitutions were reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The census was 38. 1. Review of facility provided policies showed they did not contain a policy related to food service. 2. Observation on 04/02/24 at 9:00 A.M., showed an always available menu posted in the resident dining room. The menu showed: -Hamburger or cheeseburger; -Grilled cheese special (sandwich with a side of cottage cheese); -Peanut butter and jelly special (sandwich with a side of cottage cheese); -Deli meat and cheese sandwich; -Side dishes included vegetable of the day, cottage cheese and salad of the day. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain kitchen cleanliness in a manner to prevent potential food contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. The facility staff failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. The facility census was 38. 1. Review of facility provided policies showed staff did not provide a policy related to kitchen cleaning. Review of the End of Shift Cleaning checklists for aide and cook , dated March (no year indicated), showed the checklist included clean work station for both aides and cooks. [...]

Inspectors wroteBased on record review and interviews, the facility administration failed to develop or maintain operational policy to guide the day-to-day operation of the facility. This failure had the potential to effect all staff and residents in the facility. The facility census was 38. 1. Review of facility records showed the records did not contain a guide for the day-to day functions of the facility. During an interview on 04/04/24 at 8:59 A.M., the administrator said he/she became aware the facility did not have a policy in the second week of March 2024. The current owners of the facility did not leave a policy and he/she did not develop new policy. During an interview on 04/04/24 at 1:48 P.M., the Director of Nursing (DON) said he/she did not have an answer as to why there were not policy's. The DON said there used to be a policy book kept but it couldn't be found. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The facility census was 38. 1. Review of the policies provided by the facility showed the facility did not provide a policy on antibiotic stewardship. 2. Review of the facility's Infection Control program showed the facility did not have an antibiotic stewardship program and did not contain a previous record of an antibiotic stewardship program. During an interview on 04/03/24 at 09:31 A.M., the Infection Preventionist said he/she was new to the position and the previous Infection Preventionist left suddenly. The Infection Preventionist said at this time there is not an antibiotic stewardship program, nor are there any records. The Infection Preventionist said the previous Infection Preventionist had removed all records and programs. [...]

Inspectors wroteBase on observations, interviews and record review, facility staff failed to close the computer screens from view which showed resident information when left unattended. The facility census was 38. 1. Review of the facility's policies showed staff did not provide a policy for privacy or resident rights. 2. Observation on 04/02/24 at 11:21 A.M., showed a computer kiosk on the wall next to the dining room open with resident information exposed. Observation showed staff and residents passed by the screen. Observation on 04/03/24 at 09:15 A.M., showed a computer screen open on top of a unattended medication cart outside of room [ROOM NUMBER]. Observation showed the computer contained private information visible to staff and residents. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a sanitary, comfortable and homelike environment on the 200 hallway spa/shower room, when staff failed to replace missing and/or loose baseboard on two walls and failed to keep the bathtub free from fall mats, wheelchair cushions and wheelchair leg pedals. Facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, in good repair in the 100 hall. The facility census was 38. 1. Review of the facility's policies showed staff did not provide a policy for environmental repairs, facility cleaning or homelike environment. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards of quality when staff failed to prime a insulin pen prior to insulin administration for three (Resident #6, #15, and #17) of three sampled residents and failed to ensure one resident (Resident #16) out of eight sampled residents Prothrombin and International Normalized Ratio ((PT/INR) blood test shows how long it takes to form a blood clot) and digoxin level (blood test to monitor for drug toxicity) were obtained as ordered. The facility census was 38. 1. Review of the facility's policies showed the facility did not provide a policy for insulin pens or insulin administration. Review of https://www.lillyinsulinlispro.com, Lispro Kwikpen Instructions for use, dated 09/2023, showed: -Prime the pen before each injection. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete the inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to ensure bed rails/grab bars were properly secured. Facility staff failed to obtain consents for the use of bed rails for three (Resident #6, #12, and #33) residents of 17 sampled residents and failed to obtain a physician's order for the use of bed rails for one of 17 sampled residents (Resident #12), and failed to complete bed rail use assessments for two of 17 sampled residents (Resident #6 and #12). The facility cenus was 38. 1. Review of the Facility's Side Rails policy, dated 01/23/23, showed staff are instructed as follows: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with a mobility and transfer of residents; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs for the residents by not providing in-services, re-evaluating and documenting skills and competencies on a regular basis for each employee received the required 12 hours in-service education annually. The facility census was 38. 1. Review of the facility policies provided did not contain a policy on staff annual education or in-service requirements. Review of the facilities in-service annual training did not contain documentation skills and competencies to meet the care needs for the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #13) out of two sampled residents received food in the proper form in accordance with their physician's orders. The facility census was 38. 1. Review of facility provided policies showed staff did not provide a policy related to pureed diets. Review of Resident #13's Significant Change of Status Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/02/24 showed staff assessed the resident as cognitively impaired with a diagnosis of dementia. Review of the Physician Order Sheet (POS) showed an order, dated 03/19/24, for a puree texture, regular/thin consistency diet. Review of the resident's care plan, dated 02/26/24, showed the care plan did not contain direction for diet consistency. [...]

Inspectors wroteBased on record review and interview, facility staff failed to conduct, document, or create a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility census was 38. 1. Review of facility's records showed staff did not provide a policy or guidance to develop a facility assessment. During an interview on 04/03/24 at 9:12 A.M., the administrator said the facility has no facility assessment and the previous administrator did not leave one. I have no explanation for why the assessment is not done and did not know it was required. During an interview on 04/04/24 at 1:48 P.M., the Director of Nursing said I do not know why we there is no facility assessment done. It probably should be done to operate the facility correctly.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of outbreak of Legionnaire's Disease (a serious type of lung disease caused by Legionella bacteria) (LD). [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the administration of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for two residents (Resident #4 and #35) out of six sampled residents and failed to document the administration of the influenza (contagious respiratory infection caused by a virus) vaccine for two residents (Resident #35 and #37) of six sampled residents. The facility census was 38. 1. Review of the facility's policies showed staff did not provide a policy for pneumococcal vaccines or influenza vaccines. Review of the Center for Disease Control (CDC) guidelines, dated 03/15/23, showed the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop and implement policies and procedures to ensure each resident was offered the COVID-19 (a highly contagious virus that causes serious illness or death) vaccine. Failed to ensure the residents' medical records included documentation which indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, and each dose of COVID-19 vaccine administered to the resident or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal) for three residents (Resident #4, #35, and #37) of six sampled residents. The facility census was 38. 1. Review of the Centers for Disease Control (CDC) COVID-19 Long-Term Care (LTC) Residents guidance, dated 9/25/23, showed: [...]

Inspectors wroteBased on record review and interview, facility staff failed to maintain an accurate accounting system that assured the resident fund bank statement matched the reconciliation for the same month for February 2023, March 2023, and May 2023. This had the potential to affect all residents that had funds entrusted to the facility on the residents' behalf. The facility census was 38. 1. Review of the facility's policies showed staff did not provide a policy for resident funds, reconciliation of resident funds, or surety bond. Review of the facility's accounting records, dated 02/2023 showed the record did not contain a bank statement for February 2023. Review of the facility's accounting records, dated 03/2023 showed the record did not contain a bank statement for March 2023. Review of the facility's Bank Statement, dated 05/31/2023 showed: -A beginning balance of $41,771.92; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide interventions to relieve one resident (Resident #192) pain out of one sampled resident. The facility census was 38. 1. Review of the policies provided by the facility showed the staff did not provide a policy for pain management or baseline care plans. 2. Review of Resident #192's medical record showed: -The resident admitted to the facility on [DATE]; -Diagnosis of leg wound; -Did not contain a documented, initiated, completed baseline care plan to include pain interventions. Review of the resident's hospital discharge records, dated 04/01/2024, showed the records did not contain orders for pain managment. Review of the Pain assessment dated [DATE] showed: -Currently complains of pain; -History of pain; -Used prescribed pain medications in the past; [...]

Inspectors wroteBased on interview and record review, facility staff failed to assist two residents (Resident #33 and #35) of two sampled residents assistance with transportation arrangements to and from their source of service. The facility census was 38. 1. Review of the policies provided by the facility showed the facility did not have a policy on transportation and resident appointments. 2. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/29/24 showed the resident as cognitively intact with diagnosis of migraine headache. Review of the resident's Physician Order Sheet (POS), dated 04/03/24, showed an order for a neurology consult dated 08/09/23 and 12/19/23 Review of the residents nurse notes, dated 07/13/23 through 04/04/24, showed staff documented: -On 08/09/23, resident seen by the physician, consult neurology; [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility staff failed to ensure the ice bin drained through an air gap, failed to change water filters according to manufacturer's instructions, failed to maintain the kitchen environment in a clean and sanitary manner, and failed to perform hand hygiene as often as necessary. Facility staff also failed to cover kitchen trash cans when not in use, to properly store open food to prevent cross contamination and outdated usage, and to maintain kitchen equipment in safe working order. This failure had the potential to affect all facility occupants. The facility census was 41 with a capacity of 112. 1. Review of the facility's Ice Maker policy, dated May 2015, showed the policy did not address the ice machine was to drain through an air gap. [...]

Inspectors wroteBased on observation and interview, facility staff failed to maintain a clean, comfortable and homelike environment. Facility staff failed to maintain resident restrooms free of floor discolorations and missing toilet bolt covers and caulk at the base of the toilet. In addition, the facility staff failed to maintain resident rooms free of chipped paint and discolored, chipped or missing floor tiles. The facility census was 41. 1. Review of the policies provided by staff showed staff did not provide a Facility Maintenance Policy. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility to provide an ongoing activity program to meet the needs, interests, and physical, mental and psychological well-being for for seven sampled residents (Resident #1, #2, #3, #11, #14, #21, and #23). The facility census was 41. 1. Review of the facility's Role of the Activity Director from Activity/Recreational Therapy Manual, Section 1, dated March 2012, showed the following: -The activity director provided a key role in enhancing the quality of a resident's daily life. The activity director plans and promotes meaningful activities based on the resident's interest and desire to provide a more homelike atmosphere in the facility. Review of the activity calendar provided by the facility, for the week of Sunday, March 26th through Wednesday, March 29th during annual survey, showed the following: [...]

Inspectors wroteBased on interview and record review facility staff failed to ensure the activities program was directed by a qualified professional. The census was 41. 1. Review of Activity Director Job Description, Orientation Manual, Section 2, dated May 2006, showed: Minimum Qualifications - Activity Director Certification. During an interview on 3/29/23 2:48 P.M., the Activity Director (AD) said he/she does not have any certifications or formal training and has held the title of Activity Director since September 2022. He/She said they did not know they needed to be certified in order to be given the job. During an interview on 3/29/23 at 4:00 P.M., the Administrator said the AD was not certified at this time. He/She was not aware the AD must be certified to have the position.

Inspectors wroteBased on observation, interview and record review, facility staff failed to assess the resident's risk from using side rails/bed rails, complete initial and/or annual entrapment assessments, obtain informed consent for the use of side rails and/or obtain a physician's order for three (Resident # 11, #15, and #28) sampled residents. The facility census was 41. 1. Review of the facility's Bed Rails Policy, undated, showed staff are directed to: Complete the Matrix Bed Rail Observation prior to use of bed rails to include the following: -Observation Detail; -Clinical Assessment; -Alternatives attempted prior to bed rail implementation; -Assessment of potential entrapment zones using FDA recommendations; -Review of the risk and benefits with resident and resident representative; -Obtain informed consent with resident and/or resident representative signature; [...]

Inspectors wroteBased on observation, interview, and record review staff failed to ensure medications were stored in a safe and effective manner, additionally staff failed to ensure medications carts were locked at all times. The facility census was 41. 1. Review of the facility's Medications, Storage of, from Nursing Guidelines Manual, undated, directed staff as follows: -Drugs must be stored in an orderly manner in cabinets, drawers, or carts; -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. Observation on 3/27/23 at 11:15 A.M., showed the medication cart on the North side of facility contained the following loose pills: -Three half blue and half green capsules; [...]

Inspectors wroteBased on record review and interviews, the facility staff failed to ensure residents were provided snacks at non-traditional times or outside of scheduled meal service times for four residents (Resident #6, #9, #11, and #24). The facility census was 41. 1. Review of the facility's policies showed the staff did not provide a policy for resident's rights or resident's choice. 2. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 3/1/23, showed staff assessed the resident as follows: -Cognitively intact; -Staff did not assess for resident preferences. During an interview on 3/26/23 at 1:40 P.M., the resident said snacks are horrible, when they get them, and don't always get snacks. During an interview on 3/26/23 at 1:40 P.M., Certified Nurse Assistant (CNA) N said they offer evenings snacks on the unit, if they bring them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene and glove changes during care for two (Resident #4 and #14) residents, failed to perform appropriate incontinent care for one (Resident #14) and when staff failed to maintain proper infection control practices for one resident's (Resident #1) catheter. [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications required for one resident (Resident #14) and failed to obtain an appropriate diagnosis for the use of psychotropic medication for one resident (Resident #4). The facility census was 41. 1. Review of the facility's Antipsychotic Medication Use Guideline, undated, showed: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication; [...]

Inspectors wroteBased on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check prior to employee start date for five out of 10 sampled employees (Certified Nurse Aide (CNA) B, Dietary Aide (DA) C, Activity Aide F, Laundry Aide G, and Registered Nurse (RN) I) and failed to perform a Criminal Background Check and check the Employee Disqualification List (EDL) on four out of 10 employees (DA C, Laundry Aide G, Certified Medication Technician (CMT) H, and RN I) in accordance with their policy. The facility census was 41. 1. Review of the facility's Abuse Screening policy, undated, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies in the facility assessment. The facility census was 41. 1. Review of the facility's policies showed the facility did not provide a policy for the Facility Assessment. Review of the facility's Facility Assessment, dated 10/13/22, showed staff failed to assess facility resources needed to provide competent care for residents, including numbers of staff members and a staffing plan. Review of the facility's Resident Census and Condition of Residents form, dated 3/27/23, showed a census of 41 and the following resident characteristics: -Indwelling or external catheter: 2; -Occasionally or frequently incontinent of bladder: 17; -Occasionally or frequently incontinent of bowel: 9; [...]